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LABOR Stage I_Transition Phase (Deceleration)

LABOR Stage I_Transition Phase (Deceleration) -...

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LABOR  Stage I—Transition Phase (Deceleration) The transition phase is typically the most intense of the three phases of stage I labor. It is also the shortest phase,  lasting an average of 2–3 hr in nulliparas and 1 hr in multiparas. The cervix dilates 8–10 cm as the fetus descends  approximately 1 cm/hr in nulliparas and 2 cm/hr in multiparas. CLIENT ASSESSMENT DATA BASE Circulation BP elevated 5–10 mm Hg above client’s normal level Pulse elevated Ego Integrity Irritable behavior, difficulty communicating/answering queries May have difficulty maintaining control, requiring reminders about breathing/comfort techniques May state, “I can’t stand it anymore,” or may desire to “leave the hospital and come back later” May be amnesic Elimination Urge to void or defecate throughout phase (may indicate fetus in posterior position) Food/Fluid Nausea or vomiting may occur Belching/hiccuping Pain/Discomfort Strong uterine contractions occurring every 2–3 min and lasting 60+ sec (unmedicated state). Intense level of discomfort in abdominal/sacral area. May become very restless, thrash with pain, or be fearful. May report being “too hot”; tingling sensation of fingertips, toes, and face. Leg tremors may occur. Safety Diaphoretic FHTs heard just above symphysis pubis. FHR may display variable decelerations (cord compression), late decelerations (uteroplacental insufficiency), or early  decelerations (head compression). Sexuality Cervix dilates 8–10 cm. Fetus descends 12–14 cm. Copious amounts of bloody show. NURSING PRIORITIES 1. Promote fetal and maternal well-being. 2. Provide physical and emotional support.
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NURSING DIAGNOSIS: Pain [acute] May Be Related To: Mechanical pressure of presenting part; tissue dilation/stretching and  hypoxia; stimulation of parasympathetic and sympathetic nerves;  emotional and muscular tension Possibly Evidenced By: Verbalizations, distraction behavior (e.g., restlessness), facial mask  of pain, narrowed focus, autonomic responses DESIRED OUTCOMES/EVALUATION  Verbalize perceived or actual reduction of pain. CRITERIA—CLIENT WILL: Use appropriate techniques to enhance comfort and maintain control  of labor process. Rest between contractions. ACTIONS/INTERVENTIONS RATIONALE Independent Assess degree of discomfort through verbal and  Attitudes toward pain and reactions to pain are  nonverbal cues. Assess personal and cultural  individual and based on past experiences, cultural  implications of pain. background, and self-concept.
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